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complaint

onset

hours days weeks months years
sudden gradual

new?

new issue previously known issue

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

status

improving unchanged resolved gradually worsening significant worsening

HPI

ROS
↓ normal ↓

general

+ involuntary weight loss – + fever/chills – + fatigue – + weakness –

skin

+ rash – + pruritus – + hair/nail changes –

eyes

+ change in vision – + blurry/double vision – + pain – + photophobia – + scotomata – + pain with EOM – + swelling – + redness –

head

+ headache – + head injury –

ears

+ hearing loss – + tinnitus – + earache – + ear drainage –

nose

+ congestion – + rhinorrhea – + epistaxis – + sinus pain –

throat

+ sore throat – + hoarseness – + trismus – + ulcers – + dysphagia/odynophagia –

neck

+ mass – + lymphadenopathy – + pain – + stiffness –

breast

+ masses – + pain – + discharge –

resp

+ cough – + sputum – + hemoptysis – + dyspnea – + wheezing –

cardio

+ chest pain – + palpitations – + SOBOE – + orthopnea – + PND – + edema –

+ abdo pain – + abdo distension – + heartburn – + decreased appetite –
+ nausea/vomiting – + rectal bleeding – + constipation – + diarrhea – + jaundice –

+ frequency – + urgency – + dysuria – + hematuria – + incontinence –
+ cloudy urine – + weak stream – + nocturia –

M genital

+ discharge – + erectile dysfunction – + hernia – + masses – + STI concerns –

F genital

+ dyspareunia – + dryness – + discharge – + pruritus – + STI concerns –

msk

+ joint pain – + joint swelling/redness – + stiff joints – + myalgias –

neuro

+ dizziness – + syncope – + paresthesia – + tremor – + weakness – + vertigo –

heme

+ easy bruising – + frequent epistaxis – + gum bleeding – + bleeding after surgery –

endo

+ heat/cold intolerance – + excessive sweating –
+ polyuria – + polyphagia – + polydypsia –

const

alert + acute distress – + toxic – + diaphoretic –

HENT

ears | right normal + impacted cerumen – left normal + impacted cerumen –
nose | + congestion – + rhinorrhea – + sinus pain –
mouth | + erythema – + swelling – + exudate –

eyes

PERRL N conjunctivae EOM intact + R eye discharge – + L eye discharge –

neck

normal

N rate regular rhythm tachycardia bradycardia irregular
N pulses N cap refill N heart sounds + murmur – + gallop – + friction rub –

pulm

N effort GAEB N breath sounds
+ stridor – + wheezes – + crackles – + tender chest –

abdo

normal + distension – + tenderness – + guarding – + CVA tenderness –

neuro

N gait N CN exam N coordination N DTRs N strength

normal

MSE:

general

alert and oriented obtunded disoriented

appearance

well kempt poorly kempt appropriately dressed inappropriately dressed
appropriately groomed inappropriately groomed

behavior

calm agitated interactive withdrawn
good eye contact fair eye contact avoidant eye contact

mood

euthymic depressed upbeat

affect

normal intensity expansive blunted congruent non-congruent

thought form/content

normal future oriented logical, linear and goal-oriented past-oriented and somber remorseful

attention

normal abnormal

speech

normal abnormal

insight

good fair poor

cognition/memory

normal grossly intact below average

judgement

normal fair poor

suicide/assault

none current present without intent or plan no HI

risk assessment

low moderate high

normal

Cardio

rate

normal tachycardia bradycardia

rhythm

regular irregular regularly irregular irregularly irregular

sounds

normal
+ murmur – + systolic – + diastolic – + friction rub – + gallop – + S3 – + S4 –

LE edema

none bil 1+ bil 2+

pulses

normal

Resp

effort

normal
+ accessory muscle usage – + prolonged expiration –

sounds

GAEB normal breath sounds + stridor –
+ decreased breath sounds – L: upper mid base R: upper mid base
+ wheezes – L: upper mid base R: upper mid base
+ rhonchi – L: upper mid base R: upper mid base
+ rales – L: upper mid base R: upper mid base
+ crackles – L: upper mid base R: upper mid base
+ egophony – L: upper mid base R: upper mid base

R ear

N hearing N TM N canal N external
+ impacted cerumen – + mastoid tenderness – + otorrhea – + decreased hearing –
+ canal erythema – + foreign body – + mid ear effusion – + hemotympanum –
+ bulging TM – + TM erythema – + retracted TM – + perforated TM –

L ear

Weber

does not lateralize lateralizes L lateralizes R

Rinne

R: AC>BC BC>AC L: AC>BC BC>AC

nose

normal
+ rhinorrhea – + congestion – + swelling – + septal deviation – + septal hematoma –
Turbinates normal R: + swelling – + erythema – L: + swelling – + erythema –
Sinus tenderness negative R: + frontal – + maxillary – L: + frontal – + maxillary –

throat

N mucosa N dentition N gingiva
+ trismus –
+ dental caries – + dental tenderness –
+ tongue lesions – + tongue deviation –

pharynx

normal clear uvula midline
+ swelling – + erythema –
tonsils normal + erythema – + exudate – Size grade 0 1+ 2+ 3+ 4+

Eyes:

general

PERRL lids normal no foreign body vision grossly intact
normal EOM gaze aligned
+ scleral icterus –

R eye

+ discharge – watery purulent
+ hordoleum – + stye – upper lid lower lid
A conjunctiva N + injected – + chemosis – + exudate – + conjunctival hemorrhage –
normal fluorescein

L eye

+ discharge – watery purulent
+ hordoleum – + stye – upper lid lower lid
A conjunctiva N + injected – + chemosis – + exudate – + conjunctival hemorrhage –
normal fluorescein

snellen

not tested
L 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200
R 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200

Neck exam

normal

thyroid

normal
+ mass – + thyromegaly – + tenderness –

mass

+ adenopathy –
soft, mobile, non tender reactive firm fixed + tender –

vascular

+ carotid bruit – + HJR – + JVD –

meningeal

+ Brudzinski – + Kernig –

MSK

ROM

radicular

right

normal motor

normal sensation or abnormal sensation at:

lateral arm/deltoid (C5)

lateral forearm/hand (C6)

middle finger (C7)

medial forearm/hand (C8)

medial upper arm (T1)

normal reflexes or abnormal reflexes:

biceps (C5)

brachioradialis (C6)

triceps (C7)

Hoffman

inverted radial

left

normal motor

normal sensation or abnormal sensation at:

lateral arm/deltoid (C5)

lateral forearm/hand (C6)

middle finger (C7)

medial forearm/hand (C8)

medial upper arm (T1)

normal reflexes or abnormal reflexes:

biceps (C5)

brachioradialis (C6)

triceps (C7)

Hoffman

inverted radial

normal

abdo:

flat protuberant scaphoid
+ distension – mild moderate significant

palpation

soft rigid
+ shifting dullness – + fluid wave – + hepatomegaly – + splenomegaly –
+ mass – + pulsatile mass –

+ tender –

generalized
RUQ epigastric LUQ
periumbilical
RLQ suprapubic LLQ
+ guarding – + rebound –
+ R CVA tender – + L CVA tender –
+ murphy – + mcburney – + psoas – + obturator – + rovsing –

+ hernia –

+ umbilical – + ventral – + R inguinal – + L inguinal – + R femoral – + L femoral –
soft reducible incarcerated + skin changes – + tender –

normal

Neuro:

no focal deficit

normal PERRL

sensation

intact + deficit –

motor

intact + weakness – + tremor – + pronator drift –

coord

intact + Romberg – A coordination N A finger to nose N A heel to shin N A RAM N

gait

A gait N A tandem walk N

DTR

normal, symmetric abnormal

normal (bold items)

Low Back

inspection

normal

palpation

normal

gait

heel walking (L4-5) toe walking (S1) antalgic

standing

kneeling

ankle reflex (S1)

supine

passive SLR passive hip ROM

prone

femoral nerve stretch (L3-4)

glute maximus power (S1)

saddle sensation (S2-4)

passive back extension

Assessment

Plan

O/

A/

P/